Health care providers have an ethical responsibility to recognize and appropriately care for children who are being abused or neglected. It is often up to the health care provider to initiate a humane cascade of services to protect the child, stop the abuse, and apprehend the perpetrator.  

Red flags for child abuse A health care provider needs to recognize the red flags that can signal abuse or neglect. These indicators may be behavioral or physical. If a child’s caregivers cannot give a reasonable explanation for the presence of such an indicator, this is in itself a red flag.

Health care providers need to recognize the red flags that can signal abuse or neglect.

Red flags that can signal physical abuse include:

• Injuries, including fractures and bruises at different stages of healing
• Injuries to the genitalia or anus
• Presence of sexually transmitted diseases, such as chlamydia, gonorrhea, syphilis, HIV
• Fractures, specifically of the metaphyses (ends of the shafts of long bones), ribs, vertebrae, sternum, scapulae
• Head injury with subdural hematoma
• Retinal hemorrhage
• Cerebral edema
• Complex skull fracture
• Laceration or hematoma of the liver or spleen
• Perforation of the intestines, stomach, or bladder
• Chronic, unexplained enuresis or encopresis
• Patterned injuries that indicate what was used to inflict damage:
  • Clearly demarcated scald burns
  • Symmetrical burns of the extremities
  • Burns to the buttocks
  • Adult bite marks
  • Contusions in finger-tip patterns

Red flags for neglect include:

• Failure to thrive, small size for age, falling behind in height, weight
• Emaciated appearance
• Abandonment
• Constant hunger
• Poor hygiene
• Inappropriate clothing for weather
• Lack of medical care for conditions like asthma, diabetes mellitus, dental caries
• Child reports there is no caretaker at home
• Lack of supervision has exposed the child to injury, risk, intoxication

If you see any of these red flags, you need to answer two questions:

1. Is the history provided for a condition consistent with the mechanism, type, and extent of the condition observed
2. If the child or a third party (for example, a sibling, another child in day care) is cited as the cause of an “accident,” is s/he developmentally capable of having caused the condition in the way described by the caregiver?

If the answer is no to either question, do a full work-up to rule out child abuse and neglect. Guidelines for such work-ups are provided on pages 5 and 6.

Diagnostic guidelines

The initial diagnostic work-up that a health care provider performs is of utmost importance. It often determines how well Child Protective Services and law enforcement will be able to protect the child and prosecute the perpetrator. The guidelines below and on pages 5 and 6 can be used to standardize the diagnostic work-up when child abuse or neglect is suspected.

Diagnostic Work-Up: Suspected Physical Abuse

For children younger than 2 years old, a skeletal survey should be carried out whenever abuse is suspected. For children between the ages of 2 and 5 years, a skeletal survey should be done when abuse or neglect are strongly suspected. With children older than 5 years, x-rays should be taken of skeletal areas that are sources of concern or complaint. Depending on what is learned during the surveys, additional assessment may be needed. See page 5 for more information on components of the skeletal survey and additional tests.

If sexual abuse is suspected, perform a skeletal survey if the child has visible, acute injuries. Children should be tested for sexually transmitted diseases if:

•           Genital, oral, or anal contact with the perpetrator’s secretions has occurred

•           Physical evidence exists of genital, oral, or anal trauma

•           Genital or anal discharge is present

•           The history regarding the extent of contact is not reliable

You will find more detailed information on assessing childhood sexual abuse in the summer 2003 issue of this newsletter.

Diagnostic Work-up: Suspected neglect

If you suspect a child is experiencing neglect or the denial of critical care, begin by performing a skeletal survey as you would if you suspected physical abuse.  Depending on what you learn, additional assessment may be needed; more information is provided on page 6.

Emotional abuse

If you have concerns about emotional abuse, it is wise to refer the child to mental health professional who can assess the child.

What to do if you suspect a child has been abused

If you suspect abuse, Iowa law requires you to file an abuse report with the Iowa Department of Human Services (DHS) within 24 hours of noticing that abuse.  To do this, call:  

Iowa Department of Human Services - 800-362-2178

Child in imminent danger - Call 911 and report child abuse

It is good medical practice to recommend that other children in the care of an alleged perpetrator be evaluated for possible child abuse and neglect. You will find more detailed information on the legal aspects of child abuse in the summer 2003 issue of this newsletter.
 

Child protection resources For assistance in the diagnosis and care of abused children, you can contact a child protection center near you:
Cedar Rapids	Child Protection Center St. Luke’s Hospital	319-369-7908
Davenport	Quad City Child and Family Medical Resource Center	563-421-7160
Des Moines	Regional Child Protection Center, Blank Children's Hospital	888-972-4453 515-241-4311
Iowa City	Child Assessment Clinic University of Iowa Hospitals and Clinics	319-353-6128
Sioux City	Child Advocacy Center, Mercy Hospital	800-582-0684 712-279-2548

References

• Heger, Astrid H. et al.  (eds). Evaluation of the Sexually Abused Child, 2000.

• Helfer, ME at al. (eds). The Battered Child, 1997.

• Ludwig, S and Reece, RM (eds). Child Abuse: Medical Diagnosis and Management, 2001.

• Oral, Resmiye. Intentional Head Trauma In Infants: Shaken Baby Syndrome. Virtual Children’s Hospital.